Safety and efficacy of a novel neurosurgical enhanced recovery after surgery protocol for elective craniotomy: a prospective randomized controlled trial

Effects of intraoperative low-dose esketamine on postoperative pain after vestibular schwannoma resection: A prospective randomized, double-blind, placebo-controlled study

AIMS

Esketamine may reduce acute postoperative pain in several settings. However, the effects of low-dose esketamine on postoperative pain after vestibular schwannoma (VS) resection with propofol/remifentanil total intravenous anaesthesia (TIVA) are unclear. The aim of this study is to observe the effects of intraoperative low-dose esketamine on postoperative pain after vestibular schwannoma resection.

METHODS

This single-centre, randomized, placebo-controlled, double-blind trial included 90 adults undergoing VS resection via the retrosigmoid approach with TIVA. The patients were randomly allocated to two groups: esketamine or control (n = 45 in each group). Patients received low-dose esketamine (0.2 mg/kg) or a similar volume of normal saline after dural closure. The primary outcome was the pain score during movement (gentle head movement) at 24 h postoperatively. Secondary outcomes included recovery time, bispectral index (BIS) values and haemodynamic profiles during the first 30 min after esketamine administration, and adverse effects.

RESULTS

Low-dose esketamine did not reduce pain scores at rest (P > .05) or with movement (P > .05) within the first 24 h after surgery. Esketamine moderately increased BIS values for at least 30 min after administration (P < .0001) but did not affect heart rate (P = .992) or mean arterial blood pressure (P = .994). Esketamine prolonged extubation time (P = .042, 95% confidence interval: 0.08 to 4.42) and decreased the effect-site concentration of remifentanil at extubation (P = .001, 95% confidence interval: -0.53 to -0.15) but did not affect the time to resumption of spatial orientation. Postoperative nausea and vomiting rates did not differ between groups, and no hallucinations or excessive sedation was observed.

CONCLUSION

Intraoperative low-dose esketamine did not significantly reduce acute pain after VS resection with propofol/remifentanil TIVA. However, BIS values increased for at least 30 min after esketamine administration.

Interventions facilitating the involvement of relatives of patients with acquired brain injury or malignant brain tumour: A scoping review

AIM

To identify and map the evidence on interventions facilitating the involvement of relatives of patients with an acquired brain injury (ABI) or a malignant brain tumour (MBT).

BACKGROUND

An ABI or a MBT are severe diseases that have profound impact on the lives of patients and their relatives. The well-being of the patient may be deteriorated, and relatives may experience a new role and changing caregiving tasks. Involvement of relatives seems essential, and there is a need for identifying interventions facilitating the involvement.

DESIGN

Scoping review.

METHODS

The Joanna Briggs Institute methodology was used in this review and the review was reported in accordance with the PRISMA extension for scoping reviews.

DATA SOURCES

The literature search was conducted in MEDLINE, Embase, CINAHL and Cochrane Library. Reference lists of included studies, Google Scholar and Web of Science were also searched.

RESULTS

In total, 46 studies were included of which 36 (78%) involved patients with stroke. Median duration of study interventions were 8 weeks, and nurses were involved as providers of the intervention in 23 (50%) studies. Thirty (65%) studies used a multicomponent intervention. Thirty-five unique outcomes were identified using 60 unique outcome measurements.

CONCLUSION

Interventions facilitating the involvement of relatives differed importantly in key characteristics of study interventions, and in relation to the context in which they were used. There was no consensus regarding choice of outcomes and outcome measurements. Our results highlight the complexity of interventions in this field.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

To our knowledge this is the first scoping review examining interventions facilitating the involvement of relatives of patients with an acquired brain injury or a malignant brain tumour. This review suggests a clear definition of 'involvement' in future research and there is a need of development of a core outcome set for use in interventions facilitating the involvement.

REPORTING METHOD

The scoping review was reported in accordance with the PRISMA extension for scoping reviews.

NO PATIENT OR PUBLIC CONTRIBUTION

The authors decided to undertake this scoping review without patient and public contribution. However, the protocol was published prior to review conduct and available to the public but we did not receive any comments on it.

Designing Enhanced Recovery After Surgery Protocols in Neurosurgery: A Contemporary Narrative Review

Enhanced Recovery After Surgery (ERAS) protocols have revolutionized the approach to perioperative care in various surgical specialties. They reduce complications, improve patient outcomes, and shorten hospital lengths of stay. Implementation of ERAS protocols for neurosurgical procedures has been relatively underexplored and underutilized due to the unique challenges and complexities of neurosurgery. This narrative review explores the barriers to, and pioneering strategies of, standardized procedure-specific ERAS protocols, and the importance of multidisciplinary collaboration in neurosurgery and neuroanesthsia, patient-centered approaches, and continuous quality improvement initiatives, to achieve better patient outcomes. It also discusses initiatives to guide future clinical practice, research, and guideline creation, to foster the development of tailored ERAS protocols in neurosurgery.

Enhanced Recovery After Surgery for Craniotomies: A Systematic Review and Meta-analysis

The efficacy of the enhanced recovery after surgery (ERAS) protocols in neurosurgery has not yet been established. We performed a systematic review and meta-analysis of randomized controlled trials to compare the effects of ERAS protocols and conventional perioperative care on postoperative outcomes in patients undergoing craniotomy. The primary outcome was postoperative length of hospital stay. Secondary outcomes included postoperative pain visual analog pain scores, incidence of postoperative nausea and vomiting (PONV), postoperative complications, all-cause reoperation, readmission after discharge, and mortality. A literature search up to August 10, 2023, was conducted using PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus databases. Five studies, including 871 patients, were identified for inclusion in this review. Compared with conventional perioperative care, ERAS protocols reduced the length of postoperative hospital stay (difference of medians, -1.52 days; 95% CI: -2.55 to -0.49); there was high heterogeneity across studies (I2, 74%). ERAS protocols were also associated with a lower risk of PONV (relative risk, 0.79; 95% CI: 0.69-0.90; I2, 99%) and postoperative pain with a visual analog scale score ≥4 at postoperative day 1 (relative risk, 0.37; 95% CI: 0.28-0.49; I2, 14%). Other outcomes, including postoperative complications, did not differ between ERAS and conventional care groups. ERAS protocols may be superior to conventional perioperative care in craniotomy patients in terms of lower length of hospital stay, lower incidence of PONV, and improved postoperative pain scores. Further randomized trials are required to identify the impact of ERAS protocols on the quality of recovery after craniotomy.

Enhanced recovery after surgery from 1997 to 2022: a bibliometric and visual analysis

Enhanced recovery after surgery (ERAS) is a multimodal perioperative management concept, but there is no article to comprehensively review the collaboration and impact of countries, institutions, authors, journals, references, and keywords on ERAS from a bibliometric perspective. This study assessed the evolution of clustering of knowledge structures and identified hot trends and emerging topics. Articles and reviews related to ERAS were retrieved through subject search from the Web of Science Core Collection. We used the following strategy: "TS = Enhanced recovery after surgery" OR "Enhanced Postsurgical Recovery" OR "Postsurgical Recoveries, Enhanced" OR "Postsurgical Recovery, Enhanced" OR "Recovery, Enhanced Postsurgical" OR "Fast track surgery" OR "improve surgical outcome". Bibliometric analyses were conducted on Excel 365, CiteSpace, VOSviewer, and Bibliometrics (R-Tool of R-Studio). Totally 3242 articles and reviews from 1997 to 2022 were included. These publications were mainly from 684 journals in 78 countries, led by the United States and China. Kehlet H published the most papers and had the largest number of co-citations. Analysis of the journals with the most outputs showed that most journals mainly cover Surgery and Oncology. The hottest keyword is "enhanced recovery after surgery". Later appearing topics and keywords indicate that the hotspots and future research trends include ERAS protocols for other types of surgery and improving perioperative status, including "bariatric surgery", "thoracic surgery", and "prehabilitation". This study reviewed the research on ERAS using bibliometric and visualization methods, which can help scholars better understand the dynamic evolution of ERAS and provide directions for future research.

Safety and Effectiveness of an Enhanced Recovery Protocol in Patients Undergoing Burr Hole Evacuation for Chronic Subdural Hematoma

BACKGROUND AND OBJECTIVES

Enhanced recovery programs may be especially useful in patients with chronic subdural hematoma or hygroma (cSDH), who frequently exhibit frailty and multimorbidity. We aim to evaluate the real-world safety and effectiveness of an enhanced recovery protocol in this population.

METHODS

From a prospective registry, burr hole evacuations for cSDH carried out under the protocol (including early thromboprophylaxis, no flat bed rest, early mobilization without drain clamping, and early resumption of antithrombotic medication) were extracted, along with those procedures carried out within the past year before protocol change. Propensity score-based matching was carried out. A range of clinical and imaging outcomes were analyzed, including modified Rankin Scale as effectiveness and Clavien-Dindo adverse event grading as safety primary end points.

RESULTS

Per group, 91 procedures were analyzed. At discharge, there was no significant difference in the modified Rankin Scale among the standard and enhanced recovery groups (1 [1; 2] vs 1 [1; 3], P = .552), or in Clavien-Dindo adverse event grading classifications of adverse events (P = .282) or occurrence of any adverse events (15.4% vs 20.9%, P = .442). There were no significant differences in time to drain removal (2.00 [2.00; 2.00] vs 2.00 [1.25; 2.00] days, P = .058), time from procedure to discharge (4.0 [3.0; 6.0] vs 4.0 [3.0; 6.0] days, P = .201), or total hospital length of stay (6.0 [5.0; 9.0] vs 5.0 [4.0; 8.0] days, P = .113). All-cause mortality was similar in both groups (8.8% vs 4.4%, P = .289), as was discharge disposition (P = .192). Other clinical and imaging outcomes were similar too (all P > .05).

CONCLUSION

In a matched cohort study comparing perioperative standard of care with a novel enhanced recovery protocol focusing on evidence-based drainage, mobilization, and thromboprophylaxis regimens as well as changes to the standardized reuptake of oral anticoagulants and antiaggregants, no differences in safety or effectiveness were observed after burr hole evacuation of cSDH.

Scalp Nerve Block, Local Anesthetic Infiltration, and Postoperative Pain After Craniotomy: A Systematic Review and Network Meta-analysis of Randomized Trials

The most efficacious methods for controlling postoperative pain in craniotomy remain unknown. A systematic review and network meta-analysis were performed to compare the efficacies of different strategies of scalp nerve block (SNB), scalp infiltration (SI), and control in patients undergoing craniotomy. MEDLINE, Embase, and CENTRAL databases were searched for randomized controlled trials. The primary outcome was postoperative 24-hour pain score, and the secondary outcome was opioid consumption within the first 24 hour after surgery. The effect was estimated using the between-group mean difference and ranked using the surface under the cumulative ranking curve (SUCRA) score. Twenty-four randomized trials were identified for inclusion. SNB using ropivacaine reduced postoperative 24-hour pain score when compared with control (mean difference [95% credible interval], -2.04 [-3.13, -0.94]; low quality), and when compared with SI using ropivacaine (-1.77 [-3.04, -0.51]; low quality) or bupivacaine (-1.96 [-3.65, -0.22]; low quality). SNB using ropivacaine was likely the most efficacious method for pain control (SUCRA, 91%), and also reduced opioid consumption within the first postoperative 24 hours as compared with control (mean difference [95% credible interval], -11.91 [-22.42, -1.4]; low quality). SNB using bupivacaine, lidocaine, and epinephrine combined, and SNB using ropivacaine, were likely the most efficacious methods for opioid consumption reduction (SUCRA, 88% and 80%, respectively). In summary, different methods of SNB / SI seem to have different efficacies after craniotomy. SNB using ropivacaine may be superior to other methods for postcraniotomy pain control; however, the overall quality of evidence was low.

Role of Enhanced Recovery after Surgery (ERAS) Protocol in the Management of Elderly Patients with Glioblastoma

OBJECTIVE

Among the already difficult management of neuro-oncological patients, the elderly population remains vulnerable. Because of the pathology and the comorbidities, they present a significantly higher rate of medical issues related to surgical management. Despite this, the surgical option, if feasible, remains the gold standard in these patients, and an Enhanced Recovery After Surgery (ERAS) protocol could improve the postoperative safety of the patients. With this purpose, we prepared this study with the aim of defining the postoperative hospital length of stay (LOS), but also of evaluating the postoperative morbidity, perioperative complications, and postoperative pain scores.

METHODS

This was a retrospective, single-cohort study performed at an academic hospital (Department of Neurosurgery, Neurocenter of South Switzerland, Switzerland) on elderly patients who underwent craniotomy for glioblastoma. Patients were enrolled in a novel ERAS protocol from January 2022 to December 2022. Since this is a feasibility study and a direct comparison was not possible, we used a historical cohort of elderly patients who had undergone elective craniotomy surgery for glioblastoma as a control group.

RESULTS

A total of 19 patients treated in our center for glioblastoma multiforme (GBM) who were aged over 75 years were included in this study. Among those, seven were newly recruited patients included in the ERAS protocol, while the remaining twelve were part of a historical cohort of previously treated patients. From a statistical point of view, the two cohorts were comparable in terms of baseline demographics. In the follow-up, it was shown that in the ERAS group, there was a reduction in the use of opioids after the surgical procedures that could be seen at 30 days (36.2% vs. 71.7%, p < 0.001), but also at 3 months, after surgery (33.0% vs. 80.0%, p < 0.001). A significant difference has also been documented in terms of mobilization and ambulation: compared to the historical cohort, in the ERAS group, there was a higher rate of mobilization (60.0% vs. 10.0%, p < 0.001), but also of ambulation (36.1% vs. 10.0%, p < 0.001).

CONCLUSIONS

The ERAS protocol for the management of glioblastoma in elderly patients seems to be an effective option for reducing LOS in the hospital, as well as for reducing the number of days spent in the ICU, improving the general recovery of the patient, and reducing the costs associated with hospitalization.

Management of Post-craniotomy Pain in Elective Cases: A Randomized Controlled Trial

BACKGROUND

 Craniotomy is associated with significant postoperative discomfort. Standardized pain management and enhanced recovery after surgery (ERAS) protocol could improve patient-reported outcomes and lower medical expenses.

AIM

 The aim of this study is to prospectively assess the effectiveness of an ERAS protocol for neurosurgery in the treatment of postoperative pain following elective craniotomies.

METHODS AND MATERIALS

 A total of 128 patients were assigned to the ERAS group and received care in accordance with the neurosurgical ERAS regulations, while 130 other participants were assigned to the control group and received traditional postoperative assistance. The participants' postoperative pain ratings using the numerical rating scale (NRS) were this study's main outcome of interest. The verbal NRS uses the numbers 0 to 10, with 0 indicating no sensation of pain and 10 indicating the most severe pain. On postoperative day (POD) 1, the patients' postoperative pain level at the surgical site was evaluated using the NRS. This was repeated every day until the patient either reported feeling no sensation of pain or was discharged home.

RESULTS

 The mean value of pain on the day of surgery was 4.43 ± 0.43 and 4.72 ± 0.68 for patients in the ERAS and control groups, respectively. The pain values were higher in the control group compared to the ERAS group. However, the difference was not statistically significant (p = 0.478). The mean value of pain on POD1 was 3.13 ± 0.21 and 4.45 ± 0.95 for patients in the ERAS and control groups, respectively. These pain values were higher in the control group compared to the ERAS group, and the difference was statistically significant (p = 0.011). The mean value of pain on POD2 was 2.86 ± 0.3 and 4.33 ± 0.37 for patients in the ERAS and control groups, respectively. The values of pain were higher in the control group compared to the ERAS group, and the difference was statistically significant (p = 0.003). The mean value of pain on POD3 was 2.33 ± 0.52 and 4.04 ± 0.15 for patients in the ERAS and control groups, respectively. The pain values were higher in the control group compared to the ERAS group. The difference was meaningful statistically (p < 0.001). The mean value of pain on POD4 was 2.26 ± 0.9 and 2.84 ± 0.13 for the ERAS and control groups, respectively. However, the difference was not statistically significant (p = 0.274). The ERAS group had a significantly higher proportion of participants rating their pain between 1 and 3 (68.9%) and a lower proportion rating their pain between 4 and 7 (28.2%), compared to the control group (p < 0.001). Differences in the highest pain ratings (8-10) between the groups were not statistically significant. The duration of hospital stay, beginning from surgery to discharge, was lesser among study participants in the ERAS group, and this finding was statistically significant (p < 0.001).

CONCLUSION

 The findings of this study imply that the ERAS protocol may aid pain management following elective craniotomies. Additionally, the ERAS protocol decreased the overall expense of medical care and the cumulative/postoperative length of hospital stay.

Association of the classification of intraoperative adverse events (ClassIntra) with complications and neurological outcome after neurosurgical procedures: a prospective cohort study

PURPOSE

To analyze the reliability of the classification of intraoperative adverse events (ClassIntra) to reflect intraoperative complications of neurosurgical procedures and the potential to predict the postoperative outcome including the neurological performance. The ClassIntra classification was recently introduced and found to be reliable for assessing intraoperative adverse events and predicting postoperative complications across different surgical disciplines. Nevertheless, its potential role for neurosurgical procedures remains elusive.

METHODS

This is a prospective, monocentric cohort study assessing the ClassIntra in 422 adult patients who underwent a neurosurgical procedure and were hospitalized between July 1, 2021, to December 31, 2021. The primary outcome was the occurrence of intraoperative complications graded according to ClassIntra and the association with postoperative outcome reflected by the Clavien-Dindo classification and comprehensive complication index (CCI). The ClassIntra is defined as intraoperative adverse events as any deviation from the ideal course on a grading scale from grade 0 (no deviation) to grade V (intraoperative death) and was set at sign-out in agreement between neurosurgeon and anesthesiologist. Secondary outcomes were the neurological outcome after surgery as defined by Glasgow Coma Scale (GCS), modified Rankin scale (mRS), Neurologic Assessment in Neuro-Oncology (NANO) scale, National Institute Health of Strokes Scale (NIHSS), and Karnofsky Performance Score (KPS), and need for unscheduled brain scan.

RESULTS

Of 442 patients (mean [SD] age, 56.1 [16.2]; 235 [55.7%] women and 187 [44.3%] men) who underwent a neurosurgical procedure, 169 (40.0%) patients had an intraoperative adverse event (iAE) classified as ClassIntra I or higher. The NIHSS score at admission (OR, 1.29; 95% CI, 1.03-1.63, female gender (OR, 0.44; 95% CI, 0.23-0.84), extracranial procedures (OR, 0.17; 95% CI, 0.08-0.61), and emergency cases (OR, 2.84; 95% CI, 1.53-3.78) were independent risk factors for a more severe iAE. A ClassIntra ≥ II was associated with increased odds of postoperative complications classified as Clavien-Dindo (p < 0.01), neurological deterioration at discharge (p < 0.01), prolonged hospital (p < 0.01), and ICU stay (p < 0.01). For elective craniotomies, severity of ClassIntra was associated with the CCI (p < 0.01) and need for unscheduled CT or MRI scan (p < 0.01). The proportion of a ClassIntra ≥ II was significantly higher for emergent craniotomies (56.2%) and associated with in-hospital mortality, and an unfavorable neurological outcome (p < 0.01).

CONCLUSION

Findings of this study suggest that the ClassIntra is sensitive for assessing intraoperative adverse events and sufficient to identify patients with a higher risk for developing postoperative complications after a neurosurgical procedure.

The influence of enhanced recovery after surgery protocol adherence in patients undergoing elective neuro-oncological craniotomies

Objectives

Enhanced recovery after surgery (ERAS) protocols have reduced the length of hospital stay (LOS) and healthcare costs without increasing adverse outcomes. We describe the impact of adherence to an ERAS protocol for elective craniotomy among neuro-oncology patients at a single institution.

Methods

This retrospective study enrolled adult patients who underwent elective craniotomy and the ERAS protocol at our institute between January 2020 and April 2021. The patients were divided into high- and low-adherence groups depending on their adherence to ≥9 or <9 of the 16 items, respectively. Inferential statistics were used to compare group outcomes, and multivariable logistic regression analysis was used to examine factors related to delayed discharge (LOS>7 days).

Results

Among the 100 patients assessed, median adherence was 8 items (range, 4-16), and 55 and 45 patients were classified into the high- and low-adherence groups, respectively. Age, sex, comorbidities, brain pathology, and operative profiles were comparable at baseline. The high-adherence group showed significantly better outcomes, including shorter median LOS (8 days vs. 11 days; p ​= ​0.002) and lower median hospital costs (131,657.5 baht vs. 152,974 baht; p ​= ​0.005). The groups showed no differences in 30-day postoperative complications or Karnofsky performance status. In the multivariable analysis, high adherence to the ERAS protocol (>50%) was the only significant factor preventing delayed discharge (OR ​= ​0.28; 95% CI ​= ​0.10 to 0.78; p ​= ​0.04).

Conclusions

High adherence to ERAS protocols showed a strong association with short hospital stays and cost reductions. Our ERAS protocol was feasible and safe for patients undergoing elective craniotomy for brain tumors.

The Efficacy of Scalp Nerve Block in Postoperative Pain Management after Microvascular Decompression: A Randomized Clinical Trial

The scalp nerve block, created by injecting local anesthetics around the scalp nerves, is reported to effectively reduce pain after surgery. In this study, we evaluated the efficacy of scalp nerve block in patients with hemifacial spasm (HFS) undergoing microvascular decompression (MVD). Seventy-four patients who underwent MVD for HFS were enrolled. The block group received scalp nerve block with 0.5% ropivacaine before surgery. The primary outcome was cumulative dose of rescue analgesics 24 h postoperatively. The secondary outcomes were included pain scores, postoperative antiemetic consumption, and Quality of Recovery-15 scale. The cumulative dose of rescue analgesics at 24 h postoperatively was not significantly different between the two groups (4.80 ± 3.64 mg vs. 5.92 ± 3.95 mg, p = 0.633). However, the pain score was significantly reduced in the block group at 6, 12, and 24 h postoperatively. Postoperative antiemetic consumption was lower in the block group than the control group at 12 h. There were no significant differences between the two groups for other secondary outcomes. In MVD for HFS, a preoperative scalp nerve block might reduce postoperative pain in the early postoperative period, but a larger study using a multimodal approach is needed to confirm the efficacy of a scalp block.

Effectiveness and safety of implementing an enhanced patient comfort programme for elective neurosurgical patients: a randomised controlled trial protocol

INTRODUCTION

Patient comfort is an important quality indicator of healthcare. According to Kolcaba's comfort theory, enhanced comfort is achieved by meeting the needs in four contexts: physical, psychospiritual, sociocultural and environmental. An enhanced patient comfort (EPC) programme based on this theory has been designed for elective neurosurgical patients. This study aims to assess its feasibility, effectiveness and safety.

METHODS AND ANALYSIS

The EPC programme patients will be evaluated in a single institutional randomised controlled trial. A total of 110 patients admitted for elective neurosurgery (including craniotomy, endoscopic trans-sphenoidal surgery and spine surgery) will be randomised in a 1:1 ratio to two groups. Patients in the EPC group are managed under the newly developed EPC programme, which aims to enhance patient experience and includes care coordination since admission (such as appointment of a care support coordinator, personalised setting, and cultural and spiritual support), preoperative management (such as lifestyle intervention, potential psychological and sleep intervention, and prerehabilitation), intraoperative and anaesthetic management (such as nurse coaching, music playing, and pre-emptive warming), postoperative management (such as early extubation, early diet advancement, mood and sleep management, and early ambulation) and optimised discharge planning; while those in the control group receive conventional perioperative care. The primary outcome is patient satisfaction and comfort measured by the Chinese Surgical Inpatient Satisfaction and Comfort Questionnaire. The secondary outcomes include postoperative morbidity and mortality, postoperative pain score, postoperative nausea and vomiting, functional recovery status (Karnofsky performance status and Quality of Recovery-15 score), mental status (anxiety and depression), nutritional status, health-related quality of life, hospital length of stay, reoperation and readmission rates, overall cost and patient experience.

ETHICS AND DISSEMINATION

Ethical approval to conduct the study has been obtained from Institutional Review Board of Xi'an International Medical Center (No. 202028). The results will be presented at scientific meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Chinese clinical trial registry ChiCTR2000039983.

Postoperative general medical ward admission following Chiari malformation decompression

OBJECTIVE

Prior to 2019, the majority of patients at Children's Hospital Colorado were admitted to the pediatric intensive care unit (PICU) following Chiari malformation (CM) decompression surgery. This study sought to identify the safety and efficacy of postoperative general ward management for these patients.

METHODS

After a retrospective baseline assessment of 150 patients, a quality improvement (QI) initiative was implemented, admitting medically noncomplex patients to the general ward postoperatively following CM decompression. Twenty-one medically noncomplex patients were treated during the QI intervention period. All patients were assessed for length of stay, narcotic use, time to ambulation, and postoperative complications.

RESULTS

PICU admission rates postoperatively decreased from 92.6% to 9.5% after implementation of the QI initiative. The average hospital length of stay decreased from 3.4 to 2.6 days, total doses of narcotic administration decreased from 12.3 to 8.7, and time to ambulation decreased from 1.8 to 0.9 days. There were no major postoperative complications identified that were unsuitable for management on a conventional pediatric medical/surgical nursing unit.

CONCLUSIONS

Medically noncomplex patients were safely admitted to the general ward postoperatively at Children's Hospital Colorado after decompression of CM. This approach afforded decreased length of stay, decreased narcotic use, and decreased time to ambulation, with no major postoperative complications.

Real-World Implementation of Neurosurgical Enhanced Recovery After Surgery Protocol for Gliomas in Patients Undergoing Elective Craniotomy

Objective

To design a multidisciplinary enhanced recovery after surgery (ERAS) protocol for glioma patients undergoing elective craniotomy and evaluate its clinical efficacy and safety after implementation in a tertiary neurosurgical center in China.

Methods

ERAS protocol for glioma patients was developed and modified based on the best available evidence. Patients undergoing elective craniotomy for treatment of glioma between September 2019 to May 2021 were enrolled in a randomized clinical trial comparing a conventional neurosurgical perioperative care (control group) to an ERAS protocol (ERAS group). The primary outcome was postoperative hospital length of stay (LOS). Secondary outcomes were 30-day readmission rate, postoperative complications, duration of the drainage tube, time to first oral fluid intake, time to ambulation and functional recovery status.

Results

A total of 151 patients were enrolled (ERAS group: n = 80; control group: n = 71). Compared with the control group, postoperative LOS was significantly shorter in the ERAS group (median: 5 days vs. 7 days, p<0.0001). No 30-day readmission or reoperation occurred in either group. The time of first oral intake, urinary catheter removal within 24 h and early ambulation on postoperative day (POD) 1 were earlier and shorter in the ERAS group compared with the control group (p<0.001). No statistical difference was observed between the two groups in terms of surgical- and nonsurgical-related complications. Functional recovery in terms of Karnofsky Performance Status (KPS) scores both at discharge and 30-day follow-up was similar in the two groups. Moreover, no significant difference was found between the two groups in the Hospital Anxiety and Depression Scale (HADS) scores.

Conclusion

The implementation of the ERAS protocol for glioma patients offers significant benefits over conventional neurosurgical perioperative management, as it is associated with enhancing postoperative recovery, without additional perioperative complications and risks.

Clinical Trial Registration

Chinese Clinical Trial Registry (http://www.chictr.org.cn/showproj.aspx?proj=42016), identifier ChiCTR1900025108

Enhanced Recovery After Surgery (ERAS) for Cranial Tumor Resection: A Review

Enhanced Recovery After Surgery (ERAS) protocols describe a standardized method of preoperative, perioperative, and postoperative care to enhance outcomes and minimize complication risks surrounding elective surgical intervention. A growing body of evidence is being generated as we learn to apply principles of ERAS standardization to neurosurgical patients. First applied in spinal surgery, ERAS protocols have been extended to cranial neuro-oncological procedures. This review synthesizes recent findings to generate evidence-based guidelines to manage neurosurgical oncology patients with standardized systems and assess ability of these systems to coordinate multidisciplinary, patient-centric care efforts. Furthermore, we highlight the potential utility of multimedia, app-based communication platforms to facilitate patient education, autonomy, and team communication within each of the three settings.

Retrospective Study on the Application of Enhanced Recovery After Surgery Measures to Promote Postoperative Rehabilitation in 50 Patients With Brain Tumor Undergoing Craniotomy

Objective

To investigate whether enhanced recovery after surgery (ERAS) can promote rehabilitation of patients after neurosurgical craniotomy.

Methods

The clinical data of 100 patients with brain tumor undergoing craniotomy in the Department of Neurosurgery, Xiangya Hospital, Central South University, from January 2018 to August 2020 were collected, including 50 patients in the ERAS group and 50 patients in the control group. t-Test, Wilcoxon’s rank sum test, and chi-square analysis were used to compare the clinical characteristics, prognosis, and hospitalization time between the two groups.

Results

There was no significant difference in gender, age, and other general clinical data between the two groups (p > 0.05). The days of antiemetic drugs applied in the ERAS group were less than those in the control group (1.00 vs. 2.00 days, p = 0.003), and the proportion of patients requiring analgesics was lower than that of the control group (30% vs. 52%, OR = 0.41, 95% CI 0.18–0.93, p = 0.031). The time of urinary catheter removal and that of patients starting ambulation in the ERAS group were shorter than those in the control group (16.00 vs. 24.00 h, and 1.00 vs. 2.00 days, p < 0.001, respectively); and the hospital length of stay (LOS) in the ERAS group was shorter than that in the control group (Total LOS, 13.00 vs. 15.50 days; Postoperative LOS, 7.00 vs. 10.00 days, p < 0.001). By analyzing the prognosis of patients in the ERAS group and control group, we found that there was no significant difference in postoperative complications and Karnofsky Performance Status (KPS) score 1 month after operation between the two groups.

Conclusion

The application of ERAS in craniotomy can accelerate the postoperative recovery of patients without increasing the perioperative risk, which is worthy of wide application. However, whether the ERAS measures can reduce the postoperative complications and improve the prognosis of patients still needs more large-scale case validation and multicenter collaborative study.

Complication avoidance protocols in endoscopic pituitary adenoma surgery: a retrospective cohort study in 514 patients

PURPOSE

To evaluate the impact of using consistent complication-avoidance protocols in patients undergoing endoscopic pituitary adenoma surgery including techniques for avoiding anosmia, epistaxis, carotid artery injury, hypopituitarism, cerebrospinal fluid leaks and meningitis.

METHODS

All patients undergoing endoscopic adenoma resection from 2010 to 2020 were included. Primary outcomes included 90-day complication rates, gland function outcomes, reoperations, readmissions and length of stay. Secondary outcomes were extent of resection, short-term endocrine remission, vision recovery.

RESULTS

Of 514 patients, (mean age 51 ± 16 years; 78% macroadenomas, 19% prior surgery) major complications occurred in 18(3.5%) patients, most commonly CSF leak (9, 1.7%) and meningitis (4, 0.8%). In 14 of 18 patients, complications were deemed preventable. Four (0.8%) had complications with permanent sequelae (3 before 2016): one unexplained mortality, one stroke, one oculomotor nerve palsy, one oculoparesis. There were no internal carotid artery injuries, permanent visual worsening or permanent anosmia. New hypopituitarism occurred in 23/485(4.7%). Partial or complete hypopituitarism resolution occurred in 102/193(52.8%) patients. Median LOS was 2 days; 98.3% of patients were discharged home. Comparing 18 patients with major complications versus 496 without, median LOS was 7 versus 2 days, respectively p < 0.001. Readmissions occurred in 6%(31/535), mostly for hyponatremia (18/31). Gross total resection was achieved in 214/312(69%) endocrine-inactive adenomas; biochemical remission was achieved in 148/209(71%) endocrine-active adenomas. Visual field or acuity defects improved in 126/138(91.3%) patients.

CONCLUSION

This study suggests that conformance to established protocols for endoscopic pituitary surgery may minimize complications, re-admissions and LOS while enhancing the likelihood of preserving gland function, although there remains opportunity for further improvements.

Enhanced Recovery After Surgery strategies for elective craniotomy: a systematic review

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) has led to a paradigm shift in perioperative care through multimodal interventions. Still, ERAS remains a relatively new concept in neurosurgery, and there is no summary of evidence on ERAS applications in cranial neurosurgery.

METHODS

The authors systematically reviewed the literature using the PubMed/MEDLINE, Embase, Scopus, and Cochrane Library databases for ERAS protocols and elements. Studies had to assess at least one pre-, peri-, or postoperative ERAS element and evaluate at least one of the following outcomes: 1) length of hospital stay, 2) length of ICU stay, 3) postoperative pain, 4) direct and indirect healthcare cost, 5) complication rate, 6) readmission rate, or 7) patient satisfaction.

RESULTS

A final 27 articles were included in the qualitative analysis, with mixed quality of evidence ranging from high in 3 cases to very low in 1 case. Seventeen studies reported a complete ERAS protocol. Preoperative ERAS elements include patient selection through multidisciplinary team discussion, patient counseling and education to adjust expectations of the postoperative period, and mental state assessment; antimicrobial, steroidal, and antiepileptic prophylaxes; nutritional assessment, as well as preoperative oral carbohydrate loading; and postoperative nausea and vomiting (PONV) prophylaxis. Anesthesiology interventions included local anesthesia for pin sites, regional field block or scalp block, avoidance or minimization of the duration of invasive monitoring, and limitation of intraoperative mannitol. Other intraoperative elements include absorbable skin sutures and avoidance of wound drains. Postoperatively, the authors identified early extubation, observation in a step-down unit instead of routine ICU admission, early mobilization, early fluid de-escalation, early intake of solid food and liquids, early removal of invasive monitoring, professional nutritional assessment, PONV management, nonopioid rescue analgesia, and early postoperative imaging. Other postoperative interventions included discharge criteria standardization and home visits or progress monitoring by a nurse.

CONCLUSIONS

A wide range of evidence-based interventions are available to improve recovery after elective craniotomy, although there are few published ERAS protocols. Patient-centered optimization of neurosurgical care spanning the pre-, intra-, and postoperative periods is feasible and has already provided positive results in terms of improved outcomes such as postoperative pain, patient satisfaction, reduced length of stay, and cost reduction with an excellent safety profile. Although fast-track recovery protocols and ERAS studies are gaining momentum for elective craniotomy, prospective trials are needed to provide stronger evidence.

Same day discharge for craniotomy

PURPOSE OF REVIEW

Same-day protocols for craniotomy have been demonstrated to be feasible and safe. Its several benefits include decreased hospital costs, less nosocomial complications, fewer case cancellations, with a high degree of patient satisfaction. This paper reviews the most recent publications in the field of same-day discharge after craniotomy.

RECENT FINDINGS

Since 2019, several studies on same-day neurosurgical procedures were published. Ambulatory craniotomy protocols for brain tumor were successfully implemented in more centers around the world, and for the first time, in a developing country. Additional information emerged on predictors for successful early discharge, and the barriers and enablers of same-day craniotomy programs. Moreover, the cost benefits of same-day craniotomy were reaffirmed.

SUMMARY

Same- day discharge after craniotomy is feasible, safe and continues to expand to a wider variety of procedures, in new institutions and countries. There are several benefits to ambulatory surgery. Well-established protocols for perioperative management are essential to the success of early discharge programs. With continued research, these protocols can be refined and implemented in more institutions globally, ultimately to provide better, more efficient care for neurosurgical patients.

Adapting the 5-factor modified frailty index for prediction of postprocedural outcome in patients with unruptured aneurysms

OBJECTIVE

The 5-factor modified frailty index (mFI-5) is a practical tool that can be used to estimate frailty by measuring five accessible factors: functional status, history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. The authors aimed to validate the utility of mFI-5 for predicting endovascular and microsurgical treatment outcomes in patients with unruptured aneurysms.

METHODS

A prospectively maintained database of consecutive patients with unruptured aneurysm who were treated with clip placement or endovascular therapy was used. Because patient age is an important predictor of treatment outcomes in patients with unruptured aneurysm, mFI-5 was supplemented with age to create the age-supplemented mFI-5 (AmFI-5). Associations of scores on these indices with major complications (symptomatic ischemic or hemorrhagic stroke, pulmonary embolism, pneumonia, or surgical site infection requiring reoperation) were evaluated. Validation was carried out with the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2006-2017).

RESULTS

The institutional database included 275 patients (88 underwent clip placement, and 187 underwent endovascular treatment). Multivariable analysis of the surgical cohort showed that major complication was significantly associated with mFI-5 (OR 2.0, p = 0.046) and AmFI-5 (OR 1.9, p = 0.028) scores. Significant predictive accuracy for major complications was provided by mFI-5 (c-statistic = 0.709, p = 0.011) and AmFI-5 (c-statistic = 0.720, p = 0.008). The American Society of Anesthesiologists Physical Status Classification System (ASA) provided poor discrimination (area under the curve = 0.541, p = 0.618) that was significantly less than that of mFI-5 (p = 0.023) and AmFI-5 (p = 0.014). Optimal relative fit was achieved with AmFI-5, which had the lowest Akaike information criterion value. Similar results were obtained after equivalent analysis of the endovascular cohort, with additional significant associations between index scores and length of stay (β = 0.6 and p = 0.009 for mFI-5; β = 0.5 and p = 0.003 for AmFI-5). In 1047 patients who underwent clip placement and were included in the NSQIP database, mFI-5 (p = 0.001) and AmFI-5 (p < 0.001) scores were significantly associated with severe postoperative adverse events and provided greater discrimination (c-statistic = 0.600 and p < 0.001 for mFI-5; c-statistic = 0.610 and p < 0.001 for AmFI-5) than ASA score (c-statistic = 0.580 and p = 0.003).

CONCLUSIONS

mFI-5 and AmFI-5 represent potential predictors of procedure-related complications in unruptured aneurysm patients. After further validation, integration of these tools into clinical workflows may optimize patients for intervention.

Integrated care pathways in neurosurgery: A systematic review

Introduction

Integrated care pathways (ICPs) are a pre-defined framework of evidence based, multidisciplinary practice for specific patients. They have the potential to enhance continuity of care, patient safety, patient satisfaction, efficiency gains, teamwork and staff education. In order to inform the development of neurosurgical ICPs in the future, we performed a systematic review to aggregate examples of neurosurgical ICP, to consider their impact and design features that may be associated with their success.

Methods

Electronic databases MEDLINE, EMBASE, and CENTRAL were searched for relevant literature published from date of inception to July 2020. Primary studies reporting details of neurosurgical ICPs, across all pathologies and age groups were eligible for inclusion. Patient outcomes in each case were also recorded.

Results

Twenty-four studies were included in our final dataset, from the United States, United Kingdom, Italy, China, Korea, France, Netherlands and Switzerland, and a number of sub-specialties. 3 for cerebrospinal fluid diversion, 1 functional, 2 neurovascular, 1 neuro-oncology, 2 paediatric, 2 skull base, 10 spine, 1 for trauma, 2 miscellaneous (other craniotomies). All were single centre studies with no regional or national examples. Thirteen were cohort studies while 11 were case series which lacked a control group. Effectiveness was typically evaluated using hospital or professional performance metrics, such as length of stay (n = 11, 45.8%) or adverse events (n = 17, 70.8%) including readmission, surgical complications and mortality. Patient reported outcomes, including satisfaction, were evaluated infrequently (n = 3, 12.5%). All studies reported a positive impact. No study reported how the design of the ICP was informed by published literature or other methods

Conclusions

ICPs have been successfully developed across numerous neurosurgical sub-specialities. However, there is often a lack of clarity over their design and weaknesses in their evaluation, including an underrepresentation of the patient’s perspective.

"Enhanced recovery after surgery - ERAS in elective craniotomies-a non-randomized controlled trial"

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care bundle aimed at the early recovery of patients. Well accepted in gastric and pelvic surgeries, there is minimal evidence in neurosurgery and neurocritical care barring spinal surgeries. We wished to compare the length of intensive care unit (ICU) or high dependency unit (HDU) stay of patients undergoing elective craniotomy for supratentorial neurosurgery: ERAS protocol versus routine care. The secondary objective was to compare the postoperative pain scores, opioid use, glycemic control, and the duration of postoperative hospital stay between the two groups.

METHODS

In this pragmatic non-randomized controlled trial (CTRI/2017/07/015451), consenting adult patients scheduled for elective supratentorial intracranial tumor excision were enrolled prospectively after institutional ethical clearance and consent. Elements-of-care in the ERAS group were- Preoperative -family education, complex-carbohydrate drink, flupiritine; Intraoperative - scalp blocks, limited opioids, rigorous fluid and temperature regulation; Postoperative- flupiritine, early mobilization, removal of catheters, and initiation of feeds. Apart from these, all perioperative protocols and management strategies were similar between groups. The two groups were compared with regards to the length of ICU stay, pain scores in ICU, opioid requirement, glycemic control, and hospital stay duration. The decision for discharge from ICU and hospital, data collection, and analysis was by independent assessors blind to the patient group.

RESULTS

Seventy patients were enrolled. Baseline demographics - age, sex, tumor volume, and comorbidities were comparable between the groups. The proportion of patients staying in the ICU for less than 48 h after surgery, the cumulative insulin requirement, and the episodes of VAS scores > 4 in the first 48 h after surgery was significantly less in the ERAS group - 40.6% vs. 65.7%, 0.6 (±2.5) units vs. 3.6 (±8.1) units, and one vs. ten episodes (p = 0.04, 0.001, 0.004 respectively). The total hospital stay was similar in both groups.

CONCLUSION

The study demonstrated a significant reduction in the proportion of patients requiring ICU/ HDU stay > 48 h. Better pain and glycemic control in the postoperative period may have contributed to a decreased stay. More extensive randomized studies may be designed to confirm these results.

TRIAL REGISTRATION

Clinical Trial Registry of India ( CTRI/2018/04/013247 ), registered retrospectively on April 2018.

Predicting Postoperative Outcomes in Brain Tumor Patients With a 5-Factor Modified Frailty Index

BACKGROUND

Frailty indices may represent useful decision support tools to optimize modifiable drivers of quality and cost in neurosurgical care. However, classic indices are cumbersome to calculate and frequently require unavailable data. Recently, a more lean 5-factor modified frailty index (mFI-5) was introduced, but it has not yet been rigorously applied to brain tumor patients.

OBJECTIVE

To investigate the predictive value of the mFI-5 on length of stay (LOS), complications, and charges in surgical brain tumor patients.

METHODS

We retrospectively reviewed data for brain tumor patients who underwent primary surgery from 2017 to 2018. Bivariate (ANOVA) and multivariate (logistic and linear regression) analyses assessed the predictive power of the mFI-5 on postoperative outcomes.

RESULTS

Our cohort included 1692 patients with a mean age of 55.5 yr and mFI-5 of 0.80. Mean intensive care unit (ICU) and total LOS were 1.69 and 5.24 d, respectively. Mean pulmonary embolism (PE)/deep vein thrombosis (DVT), physiological/metabolic derangement, respiratory failure, and sepsis rates were 7.2%, 1.1%, 1.6%, and 1.7%, respectively. Mean total charges were $42 331. On multivariate analysis, each additional point on the mFI-5 was associated with a 0.32- and 1.38-d increase in ICU and total LOS, respectively; increased odds of PE/DVT (odds ratio (OR): 1.50), physiological/metabolic derangement (OR: 3.66), respiratory failure (OR: 1.55), and sepsis (OR: 2.12); and an increase in total charges of $5846.

CONCLUSION

The mFI-5 is a pragmatic and actionable tool which predicts LOS, complications, and charges in brain tumor patients. It may guide future efforts to risk-stratify patients with subsequent impact on postoperative outcomes.

Improvement in the Quality of Early Postoperative Course After Endoscopic Transsphenoidal Pituitary Surgery: Description of Surgical Technique and Outcome

Objective: The endoscopic transsphenoidal pituitary surgery has gained popularity and has shown excellent results with a more comfortable postoperative course. However, the quality of the early postoperative course is not well-established in endoscopic transsphenoidal pituitary surgery. We hypothesized that the quality of the early postoperative course would be improved when an enhanced recovery after surgery (ERAS) protocol and minimally invasive endoscopic transsphenoidal pituitary surgery is implemented.

Methods: We implemented a perioperative management ERAS protocol for endoscopic transsphenoidal pituitary surgery by an experienced surgeon (Yuehui Ma) in our department from January 2018. From then the endoscopic transsphenoidal pituitary surgery was implemented with a minimally invasive technique, such as bony sella reconstruction and partial nasal packing. We compared the results of 78 endoscopic transsphenoidal pituitary surgery cases during the initiation of the ERAS protocol and minimally invasive technique implementation: 37 cases in the control group and 41 cases in the ERAS group. Outcomes assessed included the effectiveness and security of surgery, postoperative hospital length of stay (LOS), and postoperative status on postoperative day 1 (POD1).

Results: Postoperative status on POD1, such as nasal ventilation, out of bed, headache score, and liquid supplement, had significant improvement (P < 0.05). The median postoperative LOS decreased from 8 days in the control group to 3 days in the ERAS group (P < 0.05). The ERAS group had better economic benefit with fewer hospital charges (P < 0.05). There was no difference in the early postoperative diabetes insipidus and 30-day readmission for epistaxis, hyponatremia, or other complications between the two groups.

Conclusion: The quality of the early postoperative course was improved when a neurosurgical ERAS protocol and minimally invasive endoscopic transsphenoidal pituitary surgery with partially nasal packing were implemented. Endoscopic transsphenoidal pituitary day surgery could be recommended in some classes of patients though further evaluation in large case studies is warranted.

Dexmedetomidine Combined With Butorphanol or Sufentanil for the Prevention of Post-operative Nausea and Vomiting in Patients Undergoing Microvascular Decompression: A Randomized Controlled Trial

Background: Patients undergoing microvascular decompression are often accompanied with high risk of post-operative nausea and vomiting (PONV). In this study, we compare the antiemetic efficacy of butorphanol or sufentanil combined with dexmedetomidine in patients undergoing microvascular decompression.

Methods: Patients undergoing microvascular decompression were randomized into two groups. The primary outcome was the occurrence and severity of PONV during the 72 h after surgery. Secondary outcomes included levels of pain intensity and sedation and consumption of opioids at 1, 2, 6, 12, 24, 48, and 72 h after surgery. We also recorded the intraoperative hemodynamics, consumption of narcotic drugs, operation and anesthesia time, estimated blood loss, infusion volume and urine output, requirements of rescue antiemetics or analgesics, the satisfaction scores of patients and surgeons, complications, and length of stay.

Results: The overall incidence rates of nausea and vomiting during the 72 h after surgery were significantly reduced in group DB (76.00 and 44.00% in group DS vs. 54.17% and 22.92% in group DB, P < 0.05). Patients in group DB had a lower incidence of nausea than those in group DS at intervals of 1–6 and 6–24 h (P < 0.05). However, patients in group DB had a lower incidence of vomiting than those in group DS only at intervals of 1–6 h (P < 0.05). Similarly, the number of patients requiring rescue antiemetics was also significantly reduced in group DB compared with that in group DS at intervals of 1–6 h (P < 0.05). The number of patients experiencing moderate to severe PONV was comparable between the two groups during 72 h after surgery (P > 0.05). The consumption of opioid morphine equivalent was significantly reduced in group DB (P < 0.05). Compared with those in group DS, the satisfaction scores of both patients and surgeons were significantly increased in group DB (P < 0.05).

Conclusion: Butorphanol combined with dexmedetomidine could reduce early PONV and the number of patients requiring rescue antiemetics, especially at intervals of 1–6 h, while the satisfaction scores of both patients and surgeons were significantly increased.

Ambulatory Surgery Protocol for Endoscopic Endonasal Resection of Pituitary Adenomas: A Prospective Single-arm Trial with Initial Implementation Experience

Endoscopic endonasal transsphenoidal resection has been accepted as a routine therapy for pituitary adenoma, but the postoperative hospital stay is typically several days long. With the advantages of reduced cost and improved patient satisfaction, the application of ambulatory surgery (AS) has developed rapidly. However, AS was still rarely adopted in neurosurgery. Here we designed an AS treatment protocol for pituitary adenoma with the endoscopic endonasal approach (EEA), and reported our initial experiences regarding the safety and efficacy of the AS protocol. 63 patients who presented with pituitary adenoma were screened at the Department of Neurosurgery, Tangdu Hospital from July to September, 2017. A total of 20 pituitary adenoma patients who met the inclusion criteria underwent EEA surgery using this evidence-based AS protocol, which emphasized adequate assessment for eligibility, full preparation to minimize invasiveness, enhanced recovery, and active perioperative patient education. Of the 20 patients enrolled, 18 were discharged on the afternoon of the operation day with a median total length of stay (LOS) of 31 hours (range, 29–32) hours. The median LOS after surgery was 6.5 (range, 5–8) hours. Two patients were transferred from the AS protocol to conventional care due to intraoperative cerebrospinal fluid leakage (one case) and an unsatisfying post-anesthetic discharge score (one case). Complications included transient and reversible mild postoperative nausea and vomiting [visual analog scale (VAS) score <3], headache (VAS score <3) after the operation or early after discharge. No patient was readmitted. Our results supported the safety and efficacy of the AS protocol for pituitary adenoma patients undergoing EEA resection among eligible patients, and further evaluation of this protocol in controlled studies with a larger sample size is warranted.

Impact of neurosurgical enhanced recovery after surgery (ERAS) program on health-related quality of life in glioma patients: a secondary analysis of a randomized controlled trial

INTRODUCTION

A novel neurosurgical enhanced recovery after surgery (ERAS) program shortens postoperative hospital stay and accelerates functional recovery in elective craniotomy patients. There is a need to evaluate the impact of ERAS program on patients' health-related quality of life (HRQOL).

METHODS

In a single-center randomized controlled trial, patients were randomized 1:1 to receive perioperative ERAS or conventional care. As a secondary outcome, HRQOL was measured with the EORTC QLQ-C30/BN20 prior to randomization (baseline), at discharge, and at 3- and 6-month follow-up.

RESULTS

A total of 65 patients (ERAS: n = 36, conventional care: n = 29) with pathologically confirmed glioma (WHO grade 2-4) were included in the analysis. Progression-free survival at 6 months and HRQOL at baseline were similar between the two groups. Changes of scores did not vary significantly over time, but differed significantly between intervention groups. A clinically relevant better QoL (at 3-month follow-up), physical functioning (at 6-month follow-up) and role functioning (at discharge) was observed in patients in the ERAS group. Symptom scores of constipation (at discharge), motor dysfunction (at discharge, 3- and 6-month follow-up), drowsiness (at 3- and 6-month follow-up), weakness of legs (at 3-month follow-up), and nausea/vomiting (at discharge and 6-month follow-up) were significantly lower in the ERAS group.

CONCLUSIONS

The neurosurgical ERAS program seems to improve functioning and symptoms scores in glioma patients within 6-month follow-up compared with conventional care. The intervention has a significant main effect HRQOL changes without significant interaction with time. Future well-powered multicenter studies are warranted to confirm this result and address long-term benefits. This study has been registered in the Chinese Clinical Trial Registry ( http://www.chictr.org.cn/showproj.aspx?proj=16480 ) with registration number ChiCTR-INR-16009662.

Safety and costs analysis of early hospital discharge after brain tumour surgery: a pilot study

BACKGROUND

A daily algorithm for hospital discharge (DAHD) is a key point in the concept of Enhanced Recovery After Surgery (ERAS) protocol. We aimed to evaluate the length of stay (LOS), rate of complications, and hospital costs variances after the introduction of the DAHD compared to the traditional postoperative management of brain tumour patients.

METHODS

This is a cohort study with partial retrospective data collection. All consecutive patients who underwent brain tumour resection in 2017 were analysed. Demographics and procedure-related variables, as well as clinical outcomes, LOS and healthcare costs within 30 days after surgery were compared in patients before/pre-implementation and after/post-implementation the DAHD, which included: stable neurological examination; oral feeding without aspiration risk; pain control with oral medications; no intravenous medications. The algorithm was applied every morning and discharge was considered from day 1 after surgery if criteria was fulfilled. The primary outcome (LOS after surgery) analysis was adjusted for the preoperative performance status on a multivariable logistic regression model.

RESULTS

A total of 61 patients were studied (pre-implementation 32, post-implementation 29). The baseline demographic characteristics were similar between the groups. After the DAHD implementation, LOS decreased significantly (median 5 versus 3 days; p = 0.001) and the proportion of patients who were discharged on day 1 or 2 after surgery increased (44.8% vs 3.1%; p < 0.001). Major and minor complications rates, readmission rate, and unplanned return to hospital in 30-day follow-up were comparable between the groups. There was a significant reduction in the median costs of hospitalization in DAHD group (US$2135 vs US$2765, p = 0.043), mainly due to a reduction in median ward costs (US$922 vs US$1623, p = 0.009).

CONCLUSIONS

Early discharge after brain tumour surgery appears to be safe and inexpensive. The LOS and hospitalization costs were reduced without increasing readmission rate or postoperative complications.

Successful implementation of an enhanced recovery after surgery (ERAS) protocol reduces nausea and vomiting after infratentorial craniotomy for tumour resection: a randomized controlled trial

BACKGROUND

Infratentorial craniotomy patients have a high incidence of postoperative nausea and vomiting (PONV). Enhanced Recovery After Surgery (ERAS) protocols have been shown in multiple surgical disciplines to improve outcomes, including reduced PONV. However, very few studies have described the application of ERAS to infratentorial craniotomy. The aim of this study was to examine whether our ERAS protocol for infratentorial craniotomy could improve PONV.

METHODS

We implemented an evidence-based, multimodal ERAS protocol for patients undergoing infratentorial craniotomy. A total of 105 patients who underwent infratentorial craniotomy were randomized into either the ERAS group (n = 50) or the control group (n = 55). Primary outcomes were the incidence of vomiting, nausea score, and use of rescue antiemetic during the first 72 h after surgery. Secondary outcomes included postoperative anxiety level, sleep quality, and complications.

RESULTS

Over the entire 72 h post-craniotomy observation period, the cumulative incidence of vomiting was significantly lower in the ERAS group than in the control group. Meanwhile, the incidence of vomiting was significantly lower in the ERAS group on postoperative days (PODs) 2 and 3. Notably, the proportion of patients with mild nausea (VAS 0-4) was higher in the ERAS group as compared to the control group on PODs 2 or 3. Additionally, the postoperative anxiety level and quality of sleep were significantly better in the ERAS group.

CONCLUSION

Successful implementation of our ERAS protocol in infratentorial craniotomy patients could attenuate postoperative anxiety, improve sleep quality, and reduce the incidence of PONV, without increasing the rate of postoperative complications.

TRIAL REGISTRATION

ChiCTR-INR-16009662, 27 Oct 2016, Clinical study on the development and efficacy evaluation of Enhanced Recovery After Surgery (ERAS) in Neurosurgery.

International survey of neurosurgical anesthesia (iSonata) : An international survey of current practices in neurosurgical anesthesia

BACKGROUND

No standardized recommendations have been currently defined for anesthesia management of patients undergoing elective intracranial surgery. It can therefore be assumed that international clinical institutions have diverging approaches or standard operating procedures (SOP) which determine the type of general anesthesia, hemodynamic management, neuromuscular blockade, implementation of hypothermia and postoperative patient care.

OBJECTIVE

This international survey aimed to assess perioperative patient management during elective intracranial procedures. This survey was performed from February to October 2018 and 311 neurosurgical, maximum care centers across 19 European countries were contacted. The aim was to evaluate the anesthesia management to provide relevant data of neuroanesthesia practices across European centers. The survey differentiated between vascular and non-vascular as well as supratentorial and infratentorial procedures.

RESULTS

A total of 109 (35.0%) completed questionnaires from 15 European countries were analyzed. The results illustrated that total intravenous anesthesia was most commonly implemented during elective intracranial procedures (83.8%). All centers performed endotracheal intubation prior to major intracranial surgery (100%). Central venous lines were placed in 63.3% of cases. Moderate intraoperative hypothermia was carried out in 12.8% of the procedures, especially during vascular supratentorial and infratentorial surgery. A neuromuscular blockade during surgery was implemented in 74.1% of patients. Assessment of the neuromuscular junction was performed in 59.2% of cases, 76.7% of patients were immediately extubated in the operating room. 84.7% of these patients were directly transferred to a monitoring ward or an intensive care unit (ICU) and 55.1% of ventilated patients were transferred directly to an ICU.

CONCLUSION

The data demonstrate that many aspects of anesthesia management during elective intracranial surgery vary between European institutions. The data also suggest that a broad consensus exists regarding the implementation of total intravenous anesthesia, airway management (endotracheal intubation), the implementation of urinary catheters, large bore peripheral venous lines and the broad availability of cross-matched red blood cell concentrates. Nevertheless, anesthesia management (e.g. central venous catheterization, moderate hypothermia, neuromuscular monitoring) is still handled differently across many European institutions. A lack of standardized guidelines defining anesthetic management in patients undergoing intracranial procedures could explain this variability. Further studies could help establish optimal anesthesia management for these patients. This in turn could help in the development of national and international guidelines and SOPs which could define optimal management strategies for intracranial procedures.

Predictors of an Extended Length of Stay following an Elective Craniotomy in Children and Young Adults

BACKGROUND

Length of stay (LOS) is now a generally accepted clinical metric within the USA. An extended LOS following an elective craniotomy can significantly impact overall costs. Few studies have evaluated predictors of an extended LOS in pediatric neurosurgical patients.

OBJECTIVE

The aim of the study was to determine predictors of an extended hospital LOS following an elective craniotomy in children and young adults.

METHODS

All pediatric patients and young adults undergoing an elective craniotomy between January 1, 2010, and April 1, 2019, were retrospectively identified using a prospectively maintained database. Demographic, clinical, radiological, and surgical data were collected. The primary outcome was extended LOS, defined as a postsurgical stay greater than 7 days. Bivariate and multivariable analyses were performed.

RESULTS

A total of 1,498 patients underwent 1,720 elective craniotomies during the study period over the course of 1,698 hospitalizations with a median LOS of 4 days (interquartile range 3-6 days). Of these encounters, 218 (12.8%) had a prolonged LOS. Multivariable analysis demonstrated that non-Caucasian race (OR = 1.9 [African American]; OR = 1.6 [other]), the presence of an existing shunt (OR = 1.8), the type of craniotomy (OR = 0.3 [vascular relative to Chiari]), and the presence of a postoperative complication (OR = 14.7) were associated with an extended LOS.

CONCLUSIONS

Inherent and modifiable factors predict a hospital stay of more than a week in children and young adults undergoing an elective craniotomy.

Management of Postoperative Pain after Elective Craniotomy: A Prospective Randomized Controlled Trial of a Neurosurgical Enhanced Recovery after Surgery (ERAS) Program

Objective: To prospectively evaluate the efficacy of a neurosurgical enhanced recovery after surgery (ERAS) protocol on the management of postoperative pain after elective craniotomies. Methods: This randomized controlled trial was conducted in the neurosurgical center of Tangdu Hospital (Fourth Military Medical University, Xi'an, China). A total of 129 patients undergoing craniotomies between October 2016 and July 2017 were enrolled in a randomized clinical trial comparing an ERAS protocol to a conventional postoperative care regimen. The primary outcome was the postoperative pain score assessed by a verbal numerical rating scale (NRS). Results: Patients in the ERAS group had a significant reduction in their postoperative pain scores on POD 1 compared to patients in the control group (p < 0.05). More patients (n = 44, 68.8%) in the ERAS group experienced mild pain (NRS: 1 to 3) on POD1 compared with patients (n = 23, 35.4%) in the control group (p < 0.05). A further reduction in pain scores was also observed on POD 2 and maintained on POD 3 in the ERAS group compared with that in the control group. In addition, the median postoperative length of hospital stay was significantly decreased with the incorporation of the ERAS protocol compared to controls (ERAS: 4 days, control: 7 days, P<0.001). Conclusion: The implementation of a neurosurgical ERAS protocol for elective craniotomy patients has significant benefits in alleviating postoperative pain and enhancing recovery leading to early discharge after surgery compared to conventional care. Further evaluation of this protocol in larger, multi-center studies is warranted.

Neurosurgical enhanced recovery after surgery (ERAS) programme for elective craniotomies: are patients satisfied with their experiences? A quantitative and qualitative analysis

OBJECTIVE

To evaluate patient satisfaction and associated predictors at discharge, as well as patient experience at 30-day follow-up, in a neurosurgical enhanced recovery after surgery (ERAS) programme.

DESIGN

A single-centre, prospective, randomised controlled study.

SETTING

A tertiary hospital in China.

PARTICIPANTS

A total of 140 neurosurgical patients aged 18-65 years old who had a single intracranial lesion and were admitted for elective craniotomy between October 2016 and July 2017 were included.

INTERVENTIONS

Patients were randomised into two groups: 70 patients received care according to a novel neurosurgical ERAS protocol (ERAS group) and 70 patients received conventional perioperative care (control group).

OUTCOME MEASURES

Patient satisfaction at discharge was evaluated using a multimodal questionnaire. A secondary analysis of patient experience regarding participation in the ERAS programme was conducted using a semistructured qualitative interview via telephone at 30-day follow-up.

RESULTS

The mean patient satisfaction was significantly higher in the ERAS group than in the control group at discharge (92.2±4.3 vs 86.8±7.4, p=0.0001). The most important predictors of patient satisfaction included age (OR=6.934), postoperative nausea and vomiting (PONV) Visual Analogue Scale (VAS) score (OR=0.184), absorbable skin suture (OR=0.007) and postoperative length of stay (LOS) (OR=0.765). Analysis on patient experience revealed five themes: information transfer, professional support, shared responsibility and active participation, readiness for discharge, and follow-up, all of which are closely related and represent positive and negative aspects.

CONCLUSIONS

Measures that include decreasing PONV VAS score, incorporating absorbable skin suture and shortening LOS seem to increase patient satisfaction in a neurosurgical ERAS programme. Analysis of data on patient experience highlights several aspects to achieve patient-centred and high-quality care. Further studies are warranted to standardise the assessment of patient satisfaction and experience in planning, employing and appraising the ERAS programme.

TRIAL REGISTRATION NUMBER

ChiCTR-INR-16009662.

Nutrition in surgical patients: how soon is too soon?

PURPOSE OF REVIEW

Preoperative nutrition support has been extensively studied; however, data on the timing of postoperative nutrition initiation are scarce. The current review focuses on the importance of early nutritional support in surgical patients and their impact on outcomes.

RECENT FINDINGS

Early nutrition support during the postoperative course may be the most important step that can be taken toward preventing subsequent malnutrition-related complications. European Society for Parenteral and Enteral Nutrition guidelines recommends early nutrition to improve outcomes after surgery and accelerates the recovery. Moreover, nutritional support should be personalized, and disease process-based.

SUMMARY

Existing studies appear to focus mostly on abdominal and gastrointestinal surgery. Further prospective observational and randomized clinical trials across different surgical populations will aid surgeons to better understand how early feeds in either form can reduce morbidity, quality of life, and increase recovery rates.